key: cord-0958999-dvn79zao
authors: Brooker-Thompson, Chad
title: A commentary on “crisis management for surgical teams and their leaders, lessons from the COVID-19 pandemic; a structured approach to developing resilience or natural organisational responses”
date: 2021-10-22
journal: Int J Surg
DOI: 10.1016/j.ijsu.2021.106145
sha: 5a99d158476489476bfe3f2ccf5114b5221e3ce5
doc_id: 958999
cord_uid: dvn79zao

nan

It was a pleasure to read Pring et al.'s comprehensive review of crisis management strategies and their applications in the field of Surgery [1] . Crisis management and, by extension, leadership theory in general has been widely overlooked and undertaught to clinicians, which is unsustainable in the increasingly complex multidisciplinary healthcare landscape in which we work. However, I note that an important and increasingly recognised component of hierarchical leadership structures was largely ignored in this review:

Followership.

Followership is the set of qualities and actions that allow a person to successfully fulfil a subordinate role within a leadership structure. Followers represent 80% of the healthcare workforce [2] and all leaders (at some point) occupied a subordinate role.

Despite this, a cursory PubMed search for 'surgery and leadership' returns 4,810 results whilst a search for 'surgery and followership' returns just 6 articles.

It is important to bring crisis management strategies from other fields into the surgical sphere (as Pring et al. [1] have done). However, if these crisis strategies are viewed only from the point of view of 'the leader,' then the motivations, team dynamics, and follower traits of the rest of the team risk being ignored, limiting the management strategy's effectiveness. For example, Pring et al. [1] discuss the need to develop surgical leaders who, as per the military model, devolve some of the responsibility to their juniors to make 'reasoned and mature judgements,' but they do not elaborate on how we can develop junior surgeons to make these judgements, or identify juniors who possess the desirable followership style that will allow them to thrive in a decision-making role.

Followership theory can provide the contrasting 'bottom-up' view of team management that leadership focussed analysis lacks. An example of the utility of followership is to consider how followers with differing 'styles' may best fit into a team. Follower 'style' can be described by a point plotted on 2 axes: from low to high support for the leader along one axis, and low to high 'challenging' of the leader on the other [3] . When managing a crisis, a surgical leader may consider different traits desirable in subordinates assigned to different roles: a follower who has high support for the leader and seldom challenges them may be well suited to an administrative role with a clear task to complete, whereas a follower who has lower support for the leader and frequently challenges them may provide a strong contrasting opinion to the status quo, making them a desirable addition to higher level decision making discussions. There are a multitude of other applications of followership theory that are beyond the scope of this letter.

In the past, the surgical leader was seen in the context of a strict hierarchy and believed to be unquestionable and omniscient. This seems to have shaped the academic study of leadership within surgery. Surgical culture has changed and our view of leadership within surgery must change with it. We must stop viewing leadership as a rigid 'top-down' structure, where the leader exerts influence over their followers to steer the team through a crisis, and instead see it as a dynamic process where the leader is shaped by the personalities and skills of their team, and those other team members' needs, skills, and motivations are analysed and accounted for. When we review the crisis management strategies employed during the pandemic or try to apply leadership theory from the business world to our surgical practice, we must remember that successful leadership cannot exist without good followership, and that understanding how those followers adapted and flourished during the crisis is just as vital as reviewing the leadership strategies J o u r n a l P r e -p r o o f that directed them. I hope that a search of the literature in 10 years will return more than just 6 articles concerning surgery and followership: we would all do well to remember that a leader without followers does not lead at all.

"Provenance and peer review Commentary, internally reviewed"

Crisis management for surgical teams and their leaders, lessons from the COVID-19 pandemic; A structured approach to developing resilience or natural organisational responses

Followership: A review of the literature in healthcare and beyond

Followership theory: A review and research agenda